Hospital Respiratory Care | Philips

Hospital Respiratory Care Education Department August 02, 2011

Saving Face Strategies to avoid skin breakdown during NIV

Education Department, August 02, 2011 2

Focal areas

Wound Reduction

NIV Complications

Patient Assessment


Noninvasive ventilation

“There is arguably more evidence to support the use of noninvasive ventilation (NIV) than any other practice related to the care of patients with acute respiratory failure”1

NIV can also be associated with skin breakdown, leading to formation of hospital-acquired pressure sores

1Hess, D.; Patient –ventilator interaction during noninvasive ventilation. Respir Care 2011;56(2):153:165


Incidence of skin breakdown

• “Among the adverse effects of mask ventilation, skin breakdown, which occurs at the site of mask contact even after only a few hours of ventilation, is a frequent complication, ranging from 2-23%”1

• “In one study, where patients were continuously ventilated with a face mask for more than 48 hours, this percentage reached 70%”1

1Gregoretti et al. Evaluation of patient skin breakdown and comfort with a new face mask for non-invasive ventilation: a multi-center study. Inten Care Med 2002; 28:278-284.

NIV Complications


CMS reimbursement changes

• CMS classified Stage III and IV pressure ulcers as a preventable Hospital Acquired Condition (HAC)1

• No longer reimbursed by current insurance guidelines1

• Focal topic at the 2011 National Pressure Ulcer Advisory Panel (NPUAP) Meeting1

1http://www.cms.hhs.gov

NIV Complications


• Localized areas of tissue necrosis • Develop when soft tissue is compressed between a boney

prominence surface for an extended period of time

Most common on bridge of nose

Extreme cases involve surrounding areas

Pressure ulcers NIV Complications


• Shearing forces cause stretching, kinking, and tearing in the subcutaneous tissues leading to deeper tissue necrosis

• Compressive pressure should be < diastolic BP – Secondary goal is < capillary BP (32-45

mmHg) – Duration of pressure exposure is extremely

important – Pressure increases markedly over bony

prominences

DeFloor, T. The risk of pressure sores: a conceptual scheme; Jour of Clin Nursing 1999;8:206-216

Shearing forces

Pressure tolerance1 NIV Complications


• Epidermis – The outer layer of skin sheds

every 21 days • Dermis

– Contains nerve endings, blood vessels, oil glands, and sweat glands

– It also contains collagen and elastin

• Hypodermis – The subcutaneous tissue is a

layer of fat and connective tissue that houses larger blood vessels and nerves

H y p o d e r m i s

Skin anatomy and physiology NIV Complications

www.npuap.org


• Intact skin with non-blanchable redness

• A change in the skin temperature (warm or coolness)

• Tissue consistency (firm or boggy feel)

• And/or sensation (pain or itching) www.npuap.org

Pressure ulcer - Stage 1

NIV Complications


• Partial thickness loss of skin involving epidermis and/or dermis

• Presents as a intact or open serum filled blister or shallow crater

Pressure ulcer – Stage 2 NIV Complications

www.npuap.org


• Full thickness tissue loss involving damage to or necrosis of subcutaneous tissue

• May extend down to, but not through, underlying fascia

• Presents as a deep crater which may include undermining or tunneling


www.npuap.org


• Full thickness tissue loss with extensive destruction

• Exposed bone, muscle or tendon

• Some slough or eschar may be present


www.npuap.org


• All patients should be assessed for skin integrity on admission

• Assessment of risk factors for HAPU should also be determined on admission and prior to NIV initiation

– Braden scale • Relative risk should determine

monitoring frequency and prevention strategy

Initial assessment Patient Assessment

Education Department, August 02, 2011

Assessment and documentation

• Risk assessment before starting NIV • Assess all potential areas for redness

that could be impacted by respiratory devices

• Assess redness or open wounds; report findings to the primary

registered nurse • Document on the respiratory flow

sheet or the treatment plan if a wound or red area is present

• Document off-loading and/or implementation of protective devices

14

Patient Assessment

Presenter

Presentation Notes

After assessment, good documentation should follow. Risk assessment prior to starting NIV is essential. Assess all potential areas for redness that could be impacted by respiratory devices. Assess redness or open wounds and report findings to the primary registered nurse. Document on the respiratory flow sheet or the treatment plan if a wound or red area is present. Document off-loading and/or implementation of protective devices.


INITIATE BIPAP BUNDLE

Notify Supervisor and remove from service.

Apply Alternative Bipap Masks ●Total Face Mask ●Gel Face Mask ● Alternate between Total + full Masks Q4.

Adjust mask and loosen if necessary.

MD ORDER FOR BIPAP

Yes ? No ?

Skin Integrity Risk Assessment 1. Check for redness, tearing, discoloration, breakdown, etc. a. If present notify RN/ wound care. 2. Document Findings and Individual notified.

Leak <10?

Leak >10 but <25?

Subsequent Skin Assessments 1.Remove or lift protective foam dressing. 2. Check for redness, tearing, discoloration, breakdown, etc a. If present notify RN/ Wound care. 3. Document findings and individual notified.

Perform & Document Skin Integrity Risk Assessment

Huddle with Nursing

Skin Breakdown Risk Factors Should any of the following criteria apply the patient is at HIGH RISK

□ Vasopressors □ Chronic steroid therapy □ Fragile or edematous skin on face OR A patient who has any FOUR of the following criteria should be considered HIGH RISK:

□ Malnutrition □ 60yo □ DM

□ Dehydration □ Dialysis □ Anatomical factors ( Bony prominences)

□ DNR □ Restraints □ Current skin breakdown elsewhere on body

□ Neurological Impairment □ Braden Scale 18 □ COPD

Initiate Standard Face Mask

High Risk

1. Perform Subsequent Skin Assessment/document (Q2). 2. Perform Appropriate Mask Sizing + documented

4. Apply Facility Approved protective foam dressing.

3. Perform Exhalation Port Test.

5. Perform/Assess Mask Leak.

Pass? Go to step 3

Fail?

Proceed and monitor as indicated

(Protocol granted with permission)

Patient Assessment


Patient Assessment


• Clinicians remove and reposition masks many times per day1

– Mouth Care – Medication administration – Hydration – Mask breaks

• Select a mask that can be easily repositioned correctly

1Hilbert et al. Noninvasive ventilation for acute respiratory failure. Quite low time consumption for nurses Eur Respir J 2000; 16:710-716

Clinical considerations Patient Assessment

Presenter

Presentation Notes

Clinicians remove and reposition the mask many times during the day for mouth care, medication administration, hydration, and mask breaks.


Choose the right mask design

Up to 50% of NIV failures are related to the mask1

1Nava et al. Interfaces and humidification for noninvasive ventilation; Respir Care 2009; 54:71-82

Patient Assessment

Presenter

Presentation Notes

So, ask yourself, is your patient at a high risk for skin breakdown? If so, choose your options and always assess for skin breakdown.


Mask selection considerations

• Estimated length of use • Compatibility with device • Safety features

– Quick release clips – Anti-asphyxia valves

• Facial features – Skin condition – Facial abnormalities

Patient Assessment

Presenter

Presentation Notes

The estimated length of therapy, the type of delivery device, safety features, and the patient’s facial features are factors to consider when selecting a mask. For short term use or rapid application, a total face mask or full face mask may be more desirable. Once the patient has stabilized, conversion to a nasal mask may be appropriate. For long-term use, the nasal mask may be more comfortable. Consider the type of ventilator and circuit used. Some masks are designed to work only with a critical care ventilator and others with bilevel devices. For example, Respironics’ masks designed for the V60 and the BiPAP Vision ventilator do not have built-in exhalation ports, because the exhalation port is built-in to the Respironics noninvasive circuit. Using a mask with exhalation ports can cause additional leaks that reduce the flow available to the patient and can interfere with trigger sensitivities and accuracy of displayed patient data. Safety features of a total or full face mask should include a quick-release for rapid removal of mask, and a safety entrainment feature that allows the patient to breathe room air in case of ventilator failure. Masks used with a single limb circuit require an exhalation port. The facial features of every patient are unique. The size and shape of the head and nose vary from one patient to another. Skin conditions, such as aging, can cause the facial skin to become fragile and paper thin. Alternating between mask styles or use of the total face mask, which exerts relatively little pressure on the face, may be indicated to prevent pressure sores.


• Mouth breather • Claustrophobic • Level of consciousness • Cooperation • Facial structure

Patient selection considerations Patient Assessment

Presenter

Presentation Notes

Mouth breathers require a mask that covers both the mouth and nose to ensure ventilation. If a patient breathes via the mouth only at night, different masks could be used to accommodate day/night variation. The nasal mask enables easier communication and oral intake. Patients who are claustrophobic may prefer the total face mask or nasal mask. Another option is starting with a mouthpiece and switching to a mask when the patient is less anxious. A total face mask may be beneficial in patients who are confused or less responsive. Some masks come with a sizing gauge to help select the appropriate size and a quick guide to help you identify the landmarks used for sizing an mask.


• Mask types – Total face mask – Oro-nasal face mask – Nasal mask – Nasal prongs

• Headgear selection – Four-point straps – CapStrap

• Soft, self-sealing cushions – Balanced pressure on

nose, chin, and forehead • Anti-asphyxia features

Mask selection considerations Patient Assessment

Presenter

Presentation Notes

A well-fitting, comfortable mask is critical to the patient’s acceptance of and the overall success of, noninvasive ventilation. Respironics offers a wide variety of mask sizes and designs to help ensure patient comfort, minimize leaks, and improve compliance. There are three basic types of mask: the total face mask, full face mask, and the nasal mask. The total face mask covers the patient’s whole face, similar to a hockey goalie’s mask. The full face masks are designed to cover the patient’s nose and mouth. The nasal mask is either a small mask that covers the nose or a small cushion that covers the patient’s nostrils. The headgear comes in different sizes and is usually designed for a specific mask. The tension on the headgear straps should be tight enough to achieve an adequate seal, but not so tight it causes pressure sores.


Airflow and pressure-related complications of NIV

Adverse Effect Remedy Nasal congestion Try humidification or speak to the physician for

various remedies to assist with this problem

Nasal or oral dryness Add humidification, nasal saline, oral/nasal hygiene, or decrease leak

Sinus or ear pain Lower inspiratory pressure

Gastric inflation Avoid excessive inspiratory pressures (over 20 cmH2O)

Eye irritation Check mask fit, readjust bottom headgear straps

Failure to ventilate Use sufficient pressures, optimize patient-ventilator synchrony

Wound Reduction

Presenter

Presentation Notes

Air pressure and flow-related complications include oral and nasal dryness and nasal congestion, which may improve with addition of a humidification device or application of various other remedies recommended by the physician. High inspiratory pressures may be associated with sinus or ear pain and gastric distension. Readjustment of the mask and headgear can often correct eye irritation and dryness. Gastric inflation usually is not a complications when IPAP pressures are under 25 cm H2O. If higher pressures are used, positioning the patient on his/her side or in a mid to high fowlers position may help decrease the risk. In severe cases, the physician may consider prescribing an abdominal binder. Monitor the patient and be aware of their ventilatory status. Failure to ventilate could be due to not optimizing sufficient IPAP pressures to get the preferred tidal volume for the patient. This will also result in patient dysynchrony due the patient experiencing air hunger and anxiety issues.


Adverse Effect Remedy Discomfort Check fit, adjust straps, change mask

Excessive air leaks Realign mask, check strap tension, change to full face mask

Nasal bridge redness or ulceration

Use artificial skin, minimize strap tension, use spacer, alternate mask or use a PerforMax or Total face mask

Skin irritation or rashes Use skin barrier lotion and/or topical corticosteroids, change to mask made from a different material, properly clean mask

Claustrophobic reactions Try nasal mask or PerforMax or Total face mask, sedate judiciously

Mask-related complications of NIV Wound Reduction

Presenter

Presentation Notes

mask related issues account for a large portion of the reported noninvasive ventilation complications. Discomfort, air leaks, and nasal bridge erythema or ulceration can be minimized or avoided by readjusting the mask, minimizing strap tension, using forehead spacers or changing to a different mask style. A full face or total face mask will help eliminate leaks in patients without a full set of teeth. Facial skin necrosis may still occur even if the mask is not exerting high pressure on the skin. To reduce frictional forces and to minimize air leaks, use a patch or clear dressing such as Restore or Duodenum on the pressure points. Skin irritation can be caused from allergy to mask materials or improper cleaning methods. If a patient complains of claustrophobia, change the mask style.


Mask rotation practices Wound Reduction

By rotating mask designs, the pressure points are redistributed to help prevent skin breakdown

Presenter

Presentation Notes

Remember, rotation is key when it comes to preventing mask pressure sores. There are many mask types of choose from, so rotation is good.


Summary - Helping prevent pressure ulcers • Good patient assessment is essential • Identify persons at risk • Document skin integrity on

admission • Proper mask design selection

• Total face, oro-nasal, gel, nasal • Rotate designs to redistribute

pressure points • Keep mask leak no less than 7 L/min • Skin care and early interventions

• Use barriers as needed • Continuing education

Wound Reduction

Presenter

Presentation Notes

Preventing pressure ulcers is a step that needs to be taken to protect the patient and the hospital. Always identify persons at risk. Consider alternative mask styles such as the PerforMax or Total Face mask, or a gel mask. Try to keep the mask leak a minimum of 7 L/min. Dedicated NIV ventilators are designed for leaks. Always use skin care and early interventions or skin barriers. Most importantly, education and constant assessment are essential.

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